Krishna Lalit Kumar Radha, Menon Sumytra, Kanesvaran Ravindran
National University of Singapore, Singapore; Duke-NUS Graduate Medical School, Singapore; National Cancer Centre Singapore, Singapore.
Duke-NUS Graduate Medical School, Singapore.
Nurs Ethics. 2017 Aug;24(5):525-537. doi: 10.1177/0969733015617340. Epub 2015 Dec 16.
"At-own-risk discharges" or "self-discharges" evidences an irretrievable breakdown in the patient-clinician relationship when patients leave care facilities before completion of medical treatment and against medical advice. Dissolution of the therapeutic relationship terminates the physician's duty of care and professional liability with respect to care of the patient. Acquiescence of an at-own-risk discharge by the clinician is seen as respecting patient autonomy. The validity of such requests pivot on the assumptions that the patient is fully informed and competent to invoke an at-own-risk discharge and that care up to the point of the at-own-risk discharge meets prevailing clinical standards. Palliative care's use of a multidisciplinary team approach challenges both these assumptions. First by establishing multiple independent therapeutic relations between professionals in the multidisciplinary team and the patient who persists despite an at-own-risk discharge. These enduring therapeutic relationships negate the suggestion that no duty of care is owed the patient. Second, the continued employ of collusion, familial determinations, and the circumnavigation of direct patient involvement in family-centric societies compromises the patient's decision-making capacity and raises questions as to the patient's decision-making capacity and their ability to assume responsibility for the repercussions of invoking an at-own-risk discharge. With the validity of at-own-risk discharge request in question and the welfare and patient interest at stake, an alternative approach to assessing at-own-risk discharge requests are called for. The welfare model circumnavigates these concerns and preserves the patient's welfare through the employ of a multidisciplinary team guided holistic appraisal of the patient's specific situation that is informed by clinical and institutional standards and evidenced-based practice. The welfare model provides a robust decision-making framework for assessing the validity of at-own-risk discharge requests on a case-by-case basis.
“自行承担风险出院”或“自动出院”表明，当患者在未完成治疗且违背医嘱的情况下离开护理机构时，医患关系出现了无法挽回的破裂。治疗关系的解除终止了医生对患者的护理责任和职业责任。临床医生默认自行承担风险出院被视为尊重患者自主权。此类请求的有效性取决于以下假设：患者充分了解情况且有能力提出自行承担风险出院的请求，并且在自行承担风险出院之前的护理符合现行临床标准。姑息治疗采用多学科团队方法对这两个假设都提出了挑战。首先，多学科团队中的专业人员与患者之间建立了多重独立的治疗关系，即使患者自行承担风险出院，这种关系依然存在。这些持久的治疗关系否定了不欠患者护理责任的说法。其次，在以家庭为中心的社会中，持续采用串通、家庭决定以及绕过患者直接参与等做法损害了患者的决策能力，并引发了关于患者决策能力以及他们承担自行承担风险出院后果责任能力的问题。鉴于自行承担风险出院请求的有效性存在疑问且患者的福利受到影响，需要一种评估自行承担风险出院请求的替代方法。福利模式规避了这些问题，并通过采用多学科团队指导的整体评估方法来维护患者的福利，这种评估方法以临床和机构标准以及循证实践为依据，全面考量患者的具体情况。福利模式提供了一个强有力的决策框架，用于逐案评估自行承担风险出院请求的有效性。
